For many practitioners, omega-3 fatty acids are a standard part of patient care, especially when working with people at high risk of heart disease or inflammatory conditions like arthritis or chronic pain.
Holistic Primary Care's 2015 practitioner survey, which drew responses from over 650 clinicians, showed that 81% of those who routinely recommend supplements are recommending omega-3s.
Yet the vast majority takes a very broad-stroke approach.
Most practitioners base recommendations on general population guidelines like those laid out by the Dietary Reference Intakes or by organizations like the American Heart Association (AHA).
Others simply tell people to take omega-3s, and leave patients on their own to follow "serving size" recommendations on the product labels.
Either way, both practitioner and patient are flying blindly, and patients may not be getting the actual benefits of omega-3 supplementation simply because they're not taking enough.
That's unfortunate because it is easy and relatively inexpensive to test omega-3 levels in blood and tissue, and to then tailor supplementation to each patient's actual needs, based on objective measurements.
"Standard" Doesn't Mean Adequate
One could argue that there's no such thing as a "standard" dose of omega-3s guaranteed to be effective for all people. People show variability in how people digest, absorb, transport and integrate fatty acids. A number of studies have shown that the same daily dose of combined DHA and EPA results in widely divergent blood and tissue levels.
In one such study of 30 cardiac patients, a 1,000 mg daily dose of EPA/DHA (the AHA's recommended level for people with coronary artery disease) resulted in Omega-3 Index measures ranging from 4.3% to 11.2%.
The Omega-3 Index, developed by William Harris, PhD, indicates the amount of DHA and EPA incorporated into red blood cell membranes, expressed as percentage of total membrane fatty acids. It tells a lot about tissue uptake of omega-3s, correlates strongly with CVD risk, and is an important factor in considering risk reduction.
According to Harris' research, the Omega-3 Index target value is around 8%. Measurements up over 10% are highly cardioprotective; levels below 8% correlate with increased risk.
To put it in perspective, the "typical" American eating a diet low in fish and plant-based foods but high in saturated fats, refined carbs, and processed foods has an Omega-3 Index of around 4-5%.
In Harris' studies, 60% of the CVD patients on 1,000 mg of EPA/DHA failed to reach 8%. Only about 20% got up over the 8% threshold and into the really healthy zone.
Tissue is the Issue
"The tissue is the issue," says Doug Bibus, PhD, paraphrasing Bill Lands, the pioneering biochemist who first discovered the relationship between omega-3s and omega-6s, and the role of omega-3s in improving human health.
"Its not what you put in your mouth that really matters. It's what gets into the blood, and ultimately into the tissue that matters," Dr. Bibus told Holistic Primary Care.
The wide variability in individual response to a given dose of omega-3s goes a long way in explaining the divergent messages that have come from large omega-3 clinical trials.
"In the big CVD studies of late, not all of them actually measured fatty acids," said Dr. Bibus. "They were giving about 1 gram a day in those studies. There wasn't a whole lot done to measure compliance. For many people, 1,000 mg of EPA/DHA per day won't put you into the recommended blood levels."
That's important to consider when reading and interpreting the trials. Without baseline and post-intervention fatty acid measures, there's no way of knowing whether the omega-3 doses were adequate or continued long enough to bring blood and tissue levels up to the point where actual clinical benefit could be expected.
Testing in the Clinical Setting
In patients with clear cardiovascular risk, or signs of other inflammation-related disease, it makes a lot of clinical sense to test, said Dr. Bibus, who worked closely for many years with Dr. Ralph Holman, the University of Minnesota biochemist who coined the term "Omega-3," and who laid the groundwork for subsequent research in this field.
Dr. Bibus now heads a company called Lipid Technologies that leverages more than 60 years of analytical chemistry experience for clinical as well as research applications.
Lipid Technologies has translated Dr. Holman's decades of work in fatty acid analysis into a simple finger-stick bloodspot test that can provide clinicians with a wealth of information about a patient's actual fatty acid profile.
The Holman Bloodspot Test provides:
- Total omega-3 score based on circulating blood levels
- Omega-6 levels
- Omega-3 as percentage of total highly-unsaturated fatty acids (HUFA)—the so-called "Lands Test"
- Omega 3 Index
- Arachidonic Acid to EPA ratio (indicator of inflammation)
Dr. Bibus explained that each of these tests, while useful, has limitations on its own.
For example, the Omega-3 Index tells you about incorporation of omega-3s into cell membranes, but does not give any indicators about omega-6 or arachidonic acid—two key players in chronic inflammation.
Likewise, it does not tell anything about docosapentaenoic acid (DPA) an important predictor for CVD risk.
DPA: the Unknown Omega
The importance of DPA was underscored in a nested case control study of 6,438 adults. Among them, there were 94 heart attacks within a 7-year period. DPA was highly predictive of heart attack risk (low levels confer greatest risk). In fact, it was actually more predictive than EPA and ALA (Simon JA, et al. Am J Epidem; 142(5): 496-76)
DPA may serve as a reservoir of EPA and DHA. It is structurally similar to both, and very slowly oxidized. It may be present in human blood at twice the level of EPA and half the level of DHA in non-supplemented individuals. DPA inhibits platelet aggregation more efficiently than EPA or DHA, and stimulates endothelial cell migration more efficiently than EPA. Available research suggests DPA is both anti-inflammatory and neuroprotective.
Though the story on DPA is still in an early stage, it appears to be an important piece of the essential fatty acid puzzle, one worthy of greater clinical attention.
Without testing, omega-3 supplementation is largely a game of guesswork: you make a recommendation, then hope that the patient will comply and that the recommended dose will confer the expected benefit.
Testing enables you to give much more intelligent and personalized guidance. Plus, it's inexpensive! The comprehensive omega-3 test costs under $100, usually as low as $70. There is even a CPT code for it (82544--EFA testing). Insurers' willingness to pay varies widely, but this is technically a billable service.
Years ago, Dr. Lands worked out a series of equations to guide supplementation based on baseline omega-3 percentages.
- If someone scores below 30% (of total HUFA as omega-3), the suggested daily dose is 2-3 g/day of EPA/DHA.
- If someone's in the 30-40% range, 1-2 g usually suffices.
- If they're in the 40%-50% range, a 0.5-1.0 g dose is fine.
Without knowing someone's baseline values, you really don't know how much to recommend.
"The reality is, for many people at the low end of the omega spectrum, 300 mg per day isn't going to cut it. Even 1,000 mg is to be too low. You need 2,000-3,000 or even more, to get levels up to where you want them," said Dr. Bibus.
He added that even at the topmost end of Lands' dosing guidelines, one is still well within recognized safety ranges. For example, according to the European Food Safety Authority's most recent guidelines (2012):
"Long-term supplemental intakes of EPA and DHA combined up to about 5 g/day do not appear to increase the risk of spontaneous bleeding episodes or bleeding complications, or affect glucose homeostasis, immune function, or lipid peroxidation, provided the oxidative stability...is guaranteed."
Is it possible to obtain a truly healthy omega profile without supplementation? Yes, says Dr. Bibus, provided you love to eat fish.
He noted that his mentor, Dr. Holman, religiously ate two cans of sardines with two cups worth of mixed green vegetables every day. He lived to be 94 years of age, in good health, and at last measurement he had more omega-3 in his blood than omega-6.
Lipid Technologies has partnered with Nordic Naturals to familiarize more clinicians with the value of Omega-3 testing by providing two free Holman Bloodspot Tests per year for practitioners and staff. To learn more, visit: http://lipidlab.com/get-test/